This
article reviews the approach that one federal department, the Department of Housing and Urban Development (HUD) has taken
in response to recent calls for a health in all policies approach, both by Office
of Management and Budget (OMB) and notably in the cross sectoral National
Prevention Strategy. The impact of housing on health has been appreciated since
the tenement reforms around the turn of the last century. More recently HUD has
been active in lead abatement efforts; its1992 Moving
to Opportunity for Fair Housing Demonstration used vouchers to move residents
out of public housing into more affluent neighborhoods. This project showed
positive health impacts, including reductions in psychological distress,
depression, and obesity among adults.

The passage of the Affordable Care
Act (ACA) advanced health in all policies partnerships such as between HUD and
the Department of Health and Human Services (HHS), with collaboration occurring
on such projects as the Housing Capacity Building
Initiative for Community Living project, providing housing and human
services support to older adults or adults with disabilities. These types of
partnerships could be very important in coordinating diverse, yet complementary
agency interests into promoting improved public health. However, questions
remain over the long-term efficacy of such coordination, the cost/benefit ratio
of community investments to health savings, and the potential for
institutionalization. Such silo busting approaches are extremely hard to
achieve, were federal departments to develop and sustain the type of efforts
described, the population health impact could be dramatic.

This blog has
often highlighted the importance of health care cost-containment for population
health, as increasing costs absorb resources needed in for other non-medical
determinants of health. Massachusetts’ healthcare reform in 2006 provided the
precursor to the eventual passage of the ACA in 2010, and therefore provides a
frame into the long-term implications of such reform policies. Following
Massachusetts’ individual mandate in 2006, costs became of upmost importance,
because the mandate hinged on state subsidies for purchasing private insurance.
The expansion threatened the existence of the program by overwhelming the state
public insurance rolls. In response, Massachusetts moved to stiffly regulate
insurance premiums and payment systems even prior to the 2012 revision (passed
in August), but concern persisted as to whether these measure were sufficient to
properly cut costs. The 2012 revision strengthened cost-containment measures,
including working directly with providers to monitor and enforce fee limits
expanding alternative payment systems, and addressing cost disparities amongst
providers. The bipartisan nature of
these reforms, long-term commitments, and multiple approaches to cost-containment
have valuable lessons for future federal and state policies that seek to
achieve similar outcomes under the ACA framework.

I want to acknowledge the assistance of Erik Bakken, BA for his assistance in scanning the literature and drafting this post.

Journals we follow:

American Journal of Preventive Medicine

American Journal of Public Health

Annual Review of Public Health

Health Affairs

Journal of the American Medical Association (JAMA)

Journal of Epidemiology and Community Health

Journal of Health and Social Behavior

Milbank Quarterly

New England Journal of Medicine

Preventing Chronic Disease

Social Science and Medicine

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.